Vos Stone Collision - Investigation - Report - 118 - 18

Bundesstelle für Seeunfalluntersuchung
Federal Bureau of Maritime Casualty Investigation

Federal Higher Authority subordinated to the Ministry
of Transport and Digital Infrastructure
Investigation Report 118/18
Less Serious Marine Casualty
Allision between VOS STONE and a wind

turbine on 10 April 2018
in the Baltic Sea
10 April 2019
BSU
Ref.: 118/18
This investigation was conducted in conformity with the Law to

improve safety of shipping by investigating marine casualties
and other incidents (Maritime Safety Investigation Law –
SUG). According to said Law, the sole objective of this
investigation is to prevent future accidents. This investigation
does not serve to ascertain fault, liability or claims (Article 9(2)
SUG).
This report should not be used in court proceedings or

proceedings of the Maritime Board. Reference is made to
Article 34(4) SUG.
The German text shall prevail in the interpretation of this

investigation report.
Issued by:
Bundesstelle für Seeunfalluntersuchung – BSU
(Federal Bureau of Maritime Casualty Investigation)
Bernhard-Nocht-Str. 78
20359 Hamburg
Germany
Director: Ulf Kaspera

Phone: +49 40 3190 8300 Fax: +49 40 3190 8340
posteingang-bsu@bsh.de www.bsu-bund.de
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Table of Contents
1 SUMMARY ......................................................................................................... 6
2 FACTUAL INFORMATION ................................................................................. 7
2.1 Photograph of the ship ......................................................................... 7
2.2 Ship particulars..................................................................................... 7
2.3 Voyage particulars................................................................................ 8
2.4 Marine casualty or incident information ................................................ 9
2.5 Shore authority involvement and emergency response...................... 11
2.6 Definitions........................................................................................... 11
3 COURSE OF THE ACCIDENT AND INVESTIGATION ................................... 14
3.1 Course of the accident ....................................................................... 14
3.2 Damage .............................................................................................. 18
3.3 Investigation ....................................................................................... 22
3.3.1 Course of the accident ....................................................................... 22
3.3.2 Technology and processes ................................................................ 24
3.3.2.1 Switching DP ...................................................................................... 25
3.3.2.2 Equipment and maintenance .............................................................. 26
3.3.2.3 Training and process organisation ..................................................... 26
4 ANALYSIS........................................................................................................ 28
4.1 Environmental conditions ................................................................... 28
4.2 Communication .................................................................................. 28
4.3 Knowledge.......................................................................................... 29
5 CONCLUSIONS ............................................................................................... 31
6 ACTIONS TAKEN ............................................................................................ 32
7 SOURCES ....................................................................................................... 34
8 ANNEX ............................................................................................................. 35
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Table of Figures
Figure 1: Photograph of the ship ................................................................................ 7

Figure 2: Scene of the accident .................................................................................. 9
Figure 3: Scene of the accident in magnified extract of Navigational Chart 61 ......... 10
Figure 4: Initial situation at 1047 ............................................................................... 14
Figure 5: Picture of the ship's bridge ........................................................................ 15
Figure 6: Initial situation at 1053 ............................................................................... 16
Figure 7: Situation at about 1055.............................................................................. 16
Figure 10: Allision between the shipboard crane and flange deck ............................ 19
Figure 11: Damage to the nitrogen cylinder .............................................................. 19
Figure 12: Shipboard crane before and after the allision .......................................... 20
Figure 13: Damage to the outer wall of a cabin ........................................................ 21
Figure 14: Damage to the superstructure ................................................................. 21
Figure 15: Points of impact on the platform .............................................................. 21
Figure 16: First allision ............................................................................................. 23
Figure 17: Second allision ........................................................................................ 24
Figure 18: Options for controlling the ship ................................................................ 24
Figure 19: Switching procedure 1 ............................................................................. 25
Figure 20: Switching procedure 2 ............................................................................. 25
Figure 21: Internal checklist in case of collision ........................................................ 29
Figure 22: Personal checklist.................................................................................... 30
Figure 23: Flowchart showing the course of the accident ......................................... 35
Figure 24: Emergency notification chart ................................................................... 36
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Table of acronyms used
Acronym Definition
1/O Chief officer/mate
2/O Second officer/mate
AOWF Arkona Offshore Wind Farm
Autopos Automatic positioning
AWE Arkona-Windpark Entwicklungs-GmbH
C/O Chief technical officer
cJoy Compact joystick
DP Dynamic positioning
DPO DP officer (officer in charge of the navigational watch
specialised in the use of DP)
ENC Emergency notification chart
IJS Independent joystick
IMCA International Marine Contractors Association
(trade association of the shipbuilding industry)
OCM Offshore construction manager
OOW Officer on watch
QHSE Quality, health, safety, and environment
SDPO Senior dynamic positioning officer
SOV Supply offshore vessel
TP Transition piece
(foundation pillar of a wind turbine)
VBMS Company name
(Volker Wessels Boskalis Marine Solutions Holding B.V.)
VDR Voyage data recorder
VOS Vroon Offshore Services
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1 SUMMARY
At 11061 on 10 April 2018, the offshore supply vessel VOS STONE struck a wind
turbine under construction. The ship and platform were damaged and three people
on board suffered minor injuries. There was no environmental pollution. The
VOS STONE had to be repaired in a shipyard.
Due to deteriorating weather conditions, the ship collected fitters from TP AB01, a
wind turbine under construction on the AOWF (also known as
Arkona Becken Südost) in the Baltic Sea, where she was operating on behalf of
VBMS and intended to leave the area again. Just minutes after casting off from
TP AB01, the master decided to test an emergency control system, which resulted in
the loss of control of the ship. The wind and waves pushed the VOS STONE back
against TP AB01. The 1/O regained control of the ship shortly before the allision but
there was no longer sufficient time to prevent it.
The platform sustained minor damage. Three crew members on board the
VOS STONE suffered minor injuries as a result of the impact. The damage to the
ship was so bad that she had to call at a shipyard.
1
Unless stated otherwise, all times shown in this report are local = UTC + 2 (CEST).
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2 FACTUAL INFORMATION
2.1 Photograph of the ship
 VROON
Figure 1: Photograph of the ship
2.2 Ship particulars

Name of ship: VOS STONE
Type of ship: Offshore supply vessel
Nationality/Flag: Netherlands
Port of registry: Breskens
IMO number: 9730517
Call sign: PBMW
Owner: Vroon Offshore Services B.V.
Year built: 2017
Shipyard/Yard number: Fujian Southeast Shipbuilding, China
Classification society: Lloyds Register
Length overall: 80.0 m
Breadth overall: 18.40 m
Gross tonnage: 4965
Deadweight: 2348 t
Draught (max.): 5.80 m
Engine rating: 2X2400 kW
Main engine: MAK
(Service) Speed: 13 kts
Hull material: Steel
Hull design: Double bottom
Minimum safe manning: 7
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2.3 Voyage particulars

Port of departure: Mukran
Port of call: Mukran
Type of voyage: Merchant shipping/
international
Cargo information: No cargo
Manning: 23
Draught at time of accident: 5.80 m
Pilot on board: No
Canal helmsman: No
Number of passengers: 16
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2.4 Marine casualty or incident information
Type of marine casualty: Less serious marine casualty

Allision with wind turbine under
construction
Date, time: 10/04/2018, 1106
Location: AOWF (in Adlergrund)
Latitude/Longitude: φ 54°48.578'N λ 014°10.718'E
Ship operation and voyage segment: Casting off/harbour mode
Place on board: Superstructure on fore section; crane at

stern
Consequences (for people, ship, cargo, Three crew members suffered minor
environment, other): injuries; port side superstructure torn open
and aft crane damaged
Navigational Chart 61, Federal Maritime and Hydrographic Agency (BSH)
Figure 2: Scene of the accident
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Scene of the
accident
Figure 3: Scene of the accident in magnified extract of Navigational Chart 61
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2.5 Shore authority involvement and emergency response

Agencies involved: Maritime Rescue Coordination Centre (MRCC)
Bremen, Danish Maritime Authority (DMA)
Resources used: Helicopter
Actions taken: Two injured crew members taken to a hospital in
Greifswald by Helicopter
Results achieved: The three crew members injured only suffered
minor injuries; repairs to ship necessary
2.6 Definitions
Inter alia, the ship is equipped with a special navigation system due to her specific
purpose. This so-called digital positioning system on the VOS STONE makes it
necessary to begin by explaining some specific terminology. Accordingly, a
substantive list follows:
Term Explanatory notes
DP system Dynamic positioning is a computerised system which is

used to maintain the position or course of a ship using
her propellers and thrusters. Position reference sensors,
combined with wind sensors, motion sensors and
gyrocompasses, provide information to the computer
pertaining to the ship's position and the magnitude and
direction of environmental forces necessary to maintain
the ship's position.
The computer program contains a mathematical model of
the ship, which takes into account the information on
wind and current drag, as well as the position of the
thrusters. Using this and the sensor information, the
computer is able to calculate the required steering angle
and the output for the thrusters. This allows operations at
sea where mooring or anchoring is not feasible due to
deep water, objects on the seabed (pipelines, wellheads)
or other problems.
Dynamic positioning may either be absolute in that the
position is locked to a fixed point over the seabed or
relative to a moving object like another ship or a
submersible. The ship may also be positioned at a
favourable angle to wind, waves and current
(weathervaning).
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The system consists of the basic software (software

dynamic positioning – SDP), a DP controller, a DP
logger, a SDP database, as well as the stationary
devices and the cJoy and cWing mobile control panels
and can be operated in the following modes:
1) Joystick (cJoy)
2) Auto heading
3) Auto position
4) Mixed joystick/auto
5) Follow target
6) Anchor assist
7) Autopilot
8) ROT pilot
9) Auto track
10) Track line
These are described in more detail below.
1.) cJoy The cJoy control panel acts as the main operator
interface.
It can also be used as an additional joystick panel for the
cPos (compact dynamic positioning system) and SDP
parts of a DP system.
The panel is intuitive and provides user-friendly access
for keeping position and operating with automatic
steering.
2.) Auto heading The auto heading mode keeps the ship in the position set
for the longitudinal direction automatically.
3.) Auto position The auto position mode keeps the ship in the position set
automatically.
4.) Mixed The mixed joystick/auto mode allows the operator to

joystick/auto select automatic control of either one or two of the surge,
sway and yaw axes.
5.) Follow target The system follows a chosen moving target

automatically.
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6.) Anchor assist The system permanently monitors the anchor position,
using thruster assistance to maintain it.
7.) Autopilot The autopilot mode enables the ship to steer on a

predefined course automatically.
8.) ROT pilot In ROT pilot mode, the ship alters course at the
predefined rate of turn.
9.) Auto track The auto track modes (low-speed, move-up and high-
speed) allow the ship to follow a specified track
described by a set of waypoints. All auto track modes are
only for operations at sea and may not be used for
navigation purposes.
10.) Auto/track line The track line mode enables the ship to follow a constant
course over ground. The track line mode is only for
operations at sea and may not be used for navigation
purposes.
cWing The cJoy outdoor panel cWing (compact/control from the

wing) is a remote control panel for cJoy systems. The
panel is designed for outdoor installation. The cJoy
outdoor panel provides the operator with the necessary
functions to control a ship in joystick and autopilot
modes.
IJS Unlike the joystick system, the IJS is not part of the DP
system. The IJS has its own thruster and sensor
interfaces. The IJS is used both as a backup system in a
DP-S or a ship of a higher category and as a separate
system on ships not requiring comprehensive DP
functions.
Manual control Manual control2
2
See section 3.3.2 for additional explanatory notes.
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3 COURSE OF THE ACCIDENT AND INVESTIGATION

3.1 Course of the accident
On the morning of 10 April 2018, the offshore supply vessel VOS STONE was
operating in the AOWF at TP AB01, a wind turbine under construction. At about
1020, the VBMS tower work team, which was making the preparations necessary for
feeding the cable on TP AB01, was called back to the VOS STONE due to
deteriorating weather conditions. The return to the ship was carried out by means of
an Ampelmann gangway and was completed at 1047 (see Figure 4).
Wave direction 58°
Wind direction 58°
Figure 4: Initial situation at 1047
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Figure 5: Picture of the ship's bridge
At 1047, the ship left the transition piece (AB01) under DP. The following people
were on the bridge at this point: 1/O in the role of OOW/SDPO and 2/O in the role of
DPO. After the Ampelmann gangway team had reported to the bridge that all workers
were back on the ship and the completion of the personnel transfer, the 1/O
instructed the 2/O to manoeuvre the ship away from TP AB01 and out of the area
under DP (see Figure 6).
The 1/O observed the manoeuvre until he was satisfied that the 2/O had
implemented his instruction correctly and then went to the other side of the bridge to
carry out a shift handover at the port and aft entrance to the bridge and to discuss the
scope of work with the two crane operators (see Figure 7).
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Figure 6: Initial situation at 1053
Figure 7: Situation at about 1055
At this point, the master returned to the bridge to enable and test the IJS cJoy at the
forward control position. He did not notify the OOW of this. After the connection with
the console had been established, he instructed the 2/O, from his position at the aft
control position, to switch from DP to the IJS cJoy. However, since the 2/O was not
sure how to switch over, he brought the ship to a standstill using DP, while the
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master proceeded to the aft control position to show the 2/O the switch in question.
The master switched the selector from DP to cJoy before returning to the forward
control position (see Figure 8).
After this switch over, the DP system was disabled, as was the thruster control,
resulting in the ship drifting in a north-easterly wind (wind speed about 28 kts) at a
distance of about 119 m from TP AB01 (see Figure 4). The motion of wind and
waves had already turned the ship back toward the TP when the master, after going
from the aft console to the forward edge of the bridge, tried to take control by means
of the IJS cJoy, albeit unsuccessfully. He then requested assistance, at which the
1/O went to the master's position and attempted to enable the IJS. However, he only
succeeded in doing this just before the first allision.
It was not possible to regain control immediately because after switching from DP to
cJoy manually it would have been necessary to access the IJS menu screen and
then select the individual thrusters.
Unlike transferring at the joystick on the DP operator stations, which would have
made it possible to continue accessing the ship's thrusters and sensors with DP at
the touch of a button, switching the manual selector for the control mode to the IJS
(which is basically a backup system for thruster control and not affected by DP)
isolated the ship from DP control.
After the master failed to regain control of the thrusters, he requested assistance.
The 2/O notified the 1/O and asked him to assist the master at the forward console.
The 1/O hurried to assist and attempted to take manual control by asking the 2/O to
transfer control from the aft DP station. The master instructed the 2/O to switch to
manual operation, but the latter did not understand or hear this instruction and
switched the selector back to DP.
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At this point, the master wanted to know who was steering and went to check. He
found that DP mode was selected and switched back to manual mode just before the
first allision. The first allision happened at about 1102 when the VOS STONE's upper
port bulkhead struck the outer edge of the external platform of the TP on AB01,
resulting in damage to the hull level with the crew's living quarters on the port side
and thus at three empty cabins. The force of the impact lifted the support bolts of the
external platform on the flange deck out of their mounts and the deck rotated some
90° anticlockwise. The 1/O switched to full thrust at the forward steering console and
turned the ship to port, so as to move the stern away from the TP (see Figure 9). A
second allision nonetheless occurred at 1103, this time when the outer edge of the
ship's crane platform struck TP AB01's external platform.
3.2 Damage
The evidence available suggests that there was no allision between the ship and the
TP's actual primary structure but rather only between the external platform of the
flange deck and bulkhead of the crew's cabins on the port side (see Figure 10 and
Figure 11), and then subsequently with the handrails on the crane's maintenance
platform. This is where the nitrogen cylinders for the crane's swell compensator are
stored, resulting in damage to them and an ensuing release of nitrogen (see Figure
12). The handrails that were already bent caused damage to the TP's coating. As the
ship continued to move forward, the swell caused her to heel to port and the rear side
of the crane jib struck the outer edge of the flange deck, causing the flange to rotate
anticlockwise.
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The impact caused TP AB01's external platform to rotate further by about 40°
anticlockwise. The ship maintained her course and sailed out of the area.
Figure 10: Allision between the shipboard crane and flange deck
Figure 11: Damage to the nitrogen cylinder
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Figure 12: Shipboard crane before and after the allision
Three crew members suffered injuries due to the allisions. One worker was on deck
when the first allision occurred and while moving to the washer room, where he
attempted to find shelter, the second allision occurred, causing him to fall against a
container. Other crew members found him in the washer room and administered first
aid.
The second engineer was walking through a door when the first allision occurred.
Due to the impact, the door slammed shut and trapped one of his hands. The 2/O
was responsible for administering first aid on board and dressed the second
engineer's hand with a bandage.
The VOS STONE's steward was cleaning the cabins when the accident happened.
By coincidence, he was in the cabin that sustained a torn outer wall during the first
allision. After the steward initially stated that he reportedly had no physical injuries
and was merely in a state of shock, he later felt pain in one knee, as well as in his
head and neck.
Two of the three casualties were flown ashore by rescue helicopter for additional
medical care as a precautionary measure. The medical examination at the hospital
revealed that the injuries were only minor. The steward was discharged from hospital
on 11 April 2018, the worker and second engineer on 12 April 2018 and went on
leave.
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Figure 13: Damage to the outer wall of a Figure 14: Damage to the superstructure
cabin
Points of impact
Figure 15: Points of impact on the platform
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3.3 Investigation
The BSU had access to VDR recordings, AIS data from Marine Traffic, videos and
photographs from the crew and their statements. The detailed internal investigation
report of the operating company was particularly helpful.
3.3.1 Course of the accident
1020 Transfer of tower team from AB01 due to deteriorating weather

conditions.
1053 Personnel transfer via Ampelmann completed – Ampelmann system
moved to the resting position.
1053 Ship moves away from AB01 under DP.
1057 1/O confirms DP setup and course to 2/O (DPO). Crane operator at
the bridge port side door for handover briefing with 1/O. Master
returns to the bridge.
1059 Master switches from DP control to cJoy. Ship has no thruster
enabled and drifts back toward TP AB01.
• As the ship was moving away from the TP, the master intended
to switch to IJS (cJoy) on the forward navigation console and
move out further using the joystick.
• The master waited until the ship was about 80 m from the TP (it
was actually about 119 m).
• The master asked the 2/O (on the aft DP console, DPO) to
switch to cJoy mode.
• The 2/O (who had only been on board for two days) asked the
master to show him how it worked. The master showed the 2/O
how to switch the selector on the aft console to cJoy.
• The master went forward again to operate – but could not
enable the thrusters with – the IJS controls.
• The master requested assistance and the 1/O tried to help him
enable the thrusters, albeit unsuccessfully.
• When the master realised they were moving closer to TP AB01,
he issued instructions to switch to manual control.
• (However, the 2/O understood "switch to DP.")
• The astern command was then issued.
• The manual control failed to respond. The master went to the
switch and noticed that it had not been switched to manual
operation but rather to DP.
• The master switched back to manual operation.
• The 1/O took charge of the manual control on the forward
console and gave full thrust to port with an azipod, so as to
avoid another allision with the crane. This was not possible due
to the forward thrust, however.
1102 VOS STONE's first allision (port side) with TP AB01 at about 2.1 kts
(see Figure 15).
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Manual control fully regained after the thrusters were enabled and
synchronised (no speed, now with a thrust of 2.7 kts required for
control).
1103 VOS STONE's second allision (crane) with TP AB01 (see Figure 15).
1112 VBMS's OCM entered bridge in the meantime and called VBMS's
emergency number. He also arranged for the rating on watch to
make an announcement to everyone on the ship:
"All crew members should proceed to the mess."
1123 One person initially missing; search on the ship for person is
successful and everyone accounted for.
VOS STONE's master organises evacuation of casualties.
1140 Air rescue helicopter reaches VOS STONE.
1258 Bridge personnel breathalysed for alcohol. All results negative.
1341 Helicopter completes rescue mission and flies to nearest hospital on
mainland.
1430 OCM briefs the crew on current status and other safety issues.
Figure 16 shows the ship's first allision (port side level with the cabins) with the TP.
Although the thrusters had just been reenabled at this point, they did not have any
effect. The VOS STONE's ahead speed was about 2.6 kts. The allision caused the
platform to rotate about 90° anticlockwise.
Wave
direction 58°
Wind
direction 64°
AB01
Figure 16: First allision
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Figure 17 shows the second allision when the shipboard crane struck the TP at a
speed of about 2.7 kts. Control of the thrusters had been regained shortly
beforehand. This allision caused the platform to rotate a further 40° anticlockwise.
Figure 17: Second allision
3.3.2 Technology and processes

There are three modes available for controlling the VOS STONE from the bridge:
Manual, DP, cJoy.
Figure 18: Options for controlling the ship

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3.3.2.1 Switching DP
Switching from DP to IJS (cJoy) at the aft control position:
1. Switch selector from DP to cJoy (left image).
2. Confirm command on cJoy control panel by means of Take and Joystick =>
Confirm all thrusters are available and enabled (middle image).
3. Check if cJoy is responding by changing the default value and waiting for the
thrusters to respond (right image).
Selector for Figure 19: Switching procedure 1

operating mode
Switching from DP to manual on the aft control position:

1. Set DP selector to Manual (left image).
2. Apply switch over by pressing the Take CMF buttons on both azimuth levers
on the aft control position (middle image).
3. Check the thrusters by making sure they respond to the levers on the aft
control position (right image).
Selector for Figure 20: Switching procedure 2

operating mode
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3.3.2.2 Equipment and maintenance

When the ship was built, hazard studies were carried out on the DP system with
failure modes and effects analysis. Test reports from the ABS classification society
have been provided.
The operator's internal investigation report is based on an analysis of the
VOS STONE's DP recordings. No faults were found in the DP system during the
accident. The system does not record when it is switched off, however. Accordingly,
there are gaps which make it impossible to establish whether another technical
problem may actually have existed for a brief period. The electronic event logs in the
system did not reveal any problems.
Maintenance of the DP is logged in the AMOS preventative maintenance system. It
contains no entries that would have necessitated immediate action.
Recordings of the tests carried out were available on board. The DP's manufacturer
performed a new KPOS software update for the wind farm module on 5 April 2018.
No reports were found on board that would indicate any failures in the control
system.
3.3.2.3 Training and process organisation

Operating manuals were available on the bridge in printed and electronic form.
Section 1.9 of the operating manual refers to the knowledge of the systems that the
master and all DPOs must possess.
Certificates and DP logbooks were available for inspection and are up to date with
the relevant information and proofs of competence according to the training
guidelines for DP operators.
Section 2.4 of the operating manual describes the command structure on the ship. It
states that the master has authority at all times and is responsible for the ship. The
powers of a watch are specified in the master's standing orders, where point 12
reads: "Arrangement of task and responsibility with two or more navigators on the
bridge at the same time, especially in the case of DP activities. The SDPO is
responsible for the watch at all times and may assign tasks to one of the other
navigators on the bridge."
At the time of the accident, 23 people belonged to the ship's crew. The ship's
command consisted of the master, a chief mate, a 1/O (both also SDPO), two 2/Os
(both also DPO), a chief engineer, two second engineers, and one third engineer.
The bridge is always manned by two DP operators. The normal crew comprises:
chief mate (SDPO) and 2/O (Junior-DPO);
1/O (SDPO) and 2/O (Junior-DPO).
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The chief mate and 1/O alternate at 0000 and 1200 with the watch. The 2/Os change
watch at 0600 and 1800. One of the DPOs is replaced every six hours.
The master is on call around the clock and supplements the normal watch
organisation.
All navigators have experience on board ships equipped with DP and are in
possession of a full DP ticket, which serves as a certificate of competence according
to the international standard of the IMCA.
Nine nationalities were represented on board in the crew at the time of the accident
(not including the wind turbine workers). Consequently, the working language is
English.
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4 ANALYSIS
There is no indication that a technical malfunction in the DP or any other system on
board the ship played a role in the incident.
After the workers had been collected from TP AB01, the ship was moved to port
under DP so as to keep the bow facing the oncoming wind and current. In deciding to
carry out a joystick test at that position and time, the master exposed the ship to a
risk of allision with TP AB01 in the event of the system failing.
4.1 Environmental conditions

A north-easterly wind of at least 28 kts prevailed at the time of the accident. The ship
was moved away from the TP using port thrusters to keep the bow facing the wind
and waves. The speed of the current was estimated at between 1-2 kts. It was setting
in the same direction as the wind, thus pushing the vessel toward the south-west with
more force. The large 'sail area' caused by the high superstructure in the forward
third of the ship gave rise to a particular susceptibility to wind.
4.2 Communication
There is no evidence to suggest the bridge crew was under any form of duress or
stress prior to the event. As OOW, the 1/O was in command on the bridge prior to the
incident. However, the master neither communicated with the OOW nor spoke with
him about the planned IJS test when he returned to the bridge. He ultimately asked
the 2/O (as DPO) to switch to cJoy and in so doing once more ignored the 1/O (the
officer responsible for the DP system).
The operator's operating manual states the following in this regard:

6.1.1 All personnel are required to report any observation or event that may
affect the safe and efficient operating condition of the ship to the DPO. This
includes but is not limited to:
Intention to perform and notification of the completion, maintenance or
modification of any electrical or mechanical system directly affecting
online DP equipment or the availability of standby equipment.
Maintenance includes inspections and measurements.
.
.
.
6.2.4 Every officer on watch must inform the others of any planned or actual
changes in operational circumstances. Any change in a previously reported
operating condition must be reported to the officer on watch.
_____________________________________________________________________________________________________
Page 28 of 36
BSU
Ref.: 118/18
4.3 Knowledge
The DP operator's manuals are intended to ensure that all ship's personnel are
conversant with the requirements applicable and systems used on board. The
statements and evidence clearly demonstrate that the personnel were not fully
conversant with the system. The 2/O did not know how to transfer to cJoy when this
was requested and the master did not adhere to the correct transfer procedure,
either. Using the mode selector to switch to cJoy resulted in the DP system being
disabled. To select and enable the thrusters again, it would have been necessary to
access the menu screen of the IJS (cJoy).
It is also clear that there was no emergency response from the bridge immediately
after the allisions. Although there was no clarity about possible physical injuries or
material damage at this point, no count alarm was triggered for the crew, nor was a
crew check carried out. This was only set in motion at 1112 by the OCM. The OCM
on board contacted the MCC first, even though the emergency plan (see Figure 21)
and the ENC (see Annex) contain clear instructions on who has to notify whom.
CHECKLIST
V03-FLT-ERT-F-102
COLLISION
• Sound Alarm
• Call Master
• Distress message
• Inform ERT
• Inform authorities
• Communication tools established
• Muster all personnel on safe side
• Identify missing personnel
• Assess damage:
- Location
- Scale
- Tank sounding……………….Checklist
- Flooding………………………Checklist
• Consider beaching vessel
• Inform bridge
• Maintain position if locked
• Obtain ships data:
- Name
- Flag
- IMO Number
- Call sign
- Port from/to
• Provide help vessel concerned
• Prepare for abandon ship……Checklist
Figure 21: Internal checklist in case of collision
_____________________________________________________________________________________________________
Page 29 of 36
BSU
Ref.: 118/18
In accordance with requirements, the 2/O completed and signed the DPO
familiarisation checklist before the start of the shift on the previous day but it was not
countersigned by the master, which is also required in this procedure.
Figure 22: Personal checklist

_____________________________________________________________________________________________________
Page 30 of 36
BSU
Ref.: 118/18
5 CONCLUSIONS
It is not possible to say what prompted the VOS STONE's master to test the IJS after
completion of the works at TP AB01. The ship was already sailing into a freshening
wind and still within the limits of the AOWF. Accordingly, the master took an
unnecessary risk in testing the ship's emergency control system.
The 2/O was evidently not fully conversant with operating the DP. Consequently, the
ship management should continue to ensure that navigators are conversant with the
specific technology of this ship.
Internal communication between navigators on the bridge could be better. Moreover,

the master should inform the OOW of his intentions and actions, so as to avoid
complications.
Bridge management after the accident was poor.
_____________________________________________________________________________________________________
Page 31 of 36
BSU
Ref.: 118/18
6 Actions taken
Immediately after the accident, the lead operating company, VBMS, set up an
investigation committee consisting of six people, each of whom represented all the
companies involved in the project. After a detailed investigation involving interviews
with shipboard personnel and an analysis of technical recordings, an internal report
was drawn up. This report finished with a list of points (or preventive measures) that
had to be worked through before the ship was put back into service. Specifically,
these points comprised:
the training programme for new and returning DP operators must comply with
IMCA standards. The programme must be amended accordingly;
one additional, experienced SDPO should be on board to observe activities on

the bridge during the post-repair testing and in the initial phase of routine ship
operation;
the procedure for selecting the operating mode for transfer must be verified in
consultation with the sister ship and the manufacturer of the DP system,
Kongsberg;
the ship's standing orders must be updated so that they specify who is in
command during a watch and the transfer of command during the watch;
standing orders of the master should be harmonised throughout the Vroon

fleet where possible;
the annual DP tests on the VOS STONE scheduled for June 2018 will be
brought forward and performed following the repair of the ship. In each case,
the tests will be conducted in the presence of an experienced external marine
warranty surveyor commissioned by the shipowner and the end customer;
the IJS cJoy is an emergency system and should not be used while sailing
between the TPs in the construction field. Clear instructions for operating
mode selection (Manual – DP – cJoy) must be displayed on the DP control
panel;
the procedures for the switch over process must be updated in the DP
manual;
Vroon Offshore Services shall prepare and communicate to all ships of the
Vroon fleet a safety notice, which indicates the potential for error when using
the manual switch over of the DP with the IJS;
_____________________________________________________________________________________________________
Page 32 of 36
BSU
Ref.: 118/18
VBMS must send a safety notice (without ship information) to all ships of the
Boskalis fleet equipped with DP;
IMCA must be informed of the potential risk to safety on ships equipped with
DP when the operating mode is selected by inexperienced/non-familiarised
operators;
real-time emergency drills with all involved personnel, ships and rescue
services must be organised after an accident, so as to practise emergency
communication and identify any vulnerabilities in the current system before the
next entry into the construction field;
this incident must be included in the list of lessons learnt for this project;
an additional safety observer on board the VOS STONE will assist the bridge
crew in the first few days;
formalise route planning for every approach to a TP using a wind farm transit
plan;
meeting with bridge crew and AWE/VBMS;
HSE employees from AWE to attend the emergency exercise on board the
VOS STONE;
Vroon must demonstrate that the repair work has been completed
satisfactorily.
Given this commendable approach of VBMS, the BSU sees no further requirement to
issue safety recommendations.
_____________________________________________________________________________________________________
Page 33 of 36
BSU
Ref.: 118/18
7 SOURCES
• Written internal investigation report of the operating company, VBMS

• Witness testimony
• VOS STONE's VDR recordings
• Technical paper from the BSH's department responsible (Management of the
Sea)
• Navigational charts of the BSH
• Radar recordings, ship safety services/VTSs
• Photographics and video documentation of the BSU and VBMS
• Inspection of the ship by the BSU
_____________________________________________________________________________________________________
Page 34 of 36
BSU
Ref.: 118/18
8 ANNEX  VBMS
Figure 23: Flowchart showing the course of the accident
_____________________________________________________________________________________________________
Page 35 of 36
BSU
Ref.: 118/18
Figure 24: Emergency notification chart

_____________________________________________________________________________________________________
Page 36 of 36

Vos Stone Collision - Investigation - Report - 118 - 18

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Vos Stone Collision - Investigation - Report - 118 - 18

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Bundesstelle für Seeunfalluntersuchung

Federal Bureau of Maritime Casualty Investigation

Investigation Report 118/18

Less Serious Marine Casualty

Allision between VOS STONE and a wind

This investigation was conducted in conformity with the Law to

This report should not be used in court proceedings or

The German text shall prevail in the interpretation of this

Director: Ulf Kaspera

Figure 1: Photograph of the ship ................................................................................ 7

Table of acronyms used

Figure 1: Photograph of the ship

2.2 Ship particulars

2.3 Voyage particulars

2.4 Marine casualty or incident information

Type of marine casualty: Less serious marine casualty

Place on board: Superstructure on fore section; crane at

Navigational Chart 61, Federal Maritime and Hydrographic Agency (BSH)

Figure 2: Scene of the accident

Figure 3: Scene of the accident in magnified extract of Navigational Chart 61

2.5 Shore authority involvement and emergency response

Term Explanatory notes

DP system Dynamic positioning is a computerised system which is

The system consists of the basic software (software

4.) Mixed The mixed joystick/auto mode allows the operator to

5.) Follow target The system follows a chosen moving target

7.) Autopilot The autopilot mode enables the ship to steer on a

cWing The cJoy outdoor panel cWing (compact/control from the

Manual control Manual control2

3 COURSE OF THE ACCIDENT AND INVESTIGATION

Wave direction 58°

Wind direction 58°

Figure 4: Initial situation at 1047

Figure 5: Picture of the ship's bridge

Figure 6: Initial situation at 1053

Figure 7: Situation at about 1055

Figure 8: Situation at about 1059

Figure 9: Situation at about 1101

Figure 11: Damage to the nitrogen cylinder

Figure 12: Shipboard crane before and after the allision

Figure 15: Points of impact on the platform

3.3.1 Course of the accident

1020 Transfer of tower team from AB01 due to deteriorating weather

Figure 16: First allision

Figure 17: Second allision

3.3.2 Technology and processes

Figure 18: Options for controlling the ship

Selector for Figure 19: Switching procedure 1

Switching from DP to manual on the aft control position:

Selector for Figure 20: Switching procedure 2

3.3.2.2 Equipment and maintenance

3.3.2.3 Training and process organisation

4.1 Environmental conditions

The operator's operating manual states the following in this regard:

Figure 21: Internal checklist in case of collision

Figure 22: Personal checklist

Internal communication between navigators on the bridge could be better. Moreover,

Bridge management after the accident was poor.

one additional, experienced SDPO should be on board to observe activities on

standing orders of the master should be harmonised throughout the Vroon

meeting with bridge crew and AWE/VBMS;

• Written internal investigation report of the operating company, VBMS